CO-OP I – Introduction

The ability for people to perform everyday activities has an important impact on self-esteem, social opportunities, academic success and quality of life. These activities can include anything that people need to do, want to do, or are expected to do, such as riding a bicycle, using utensils during meals or planning a vacation. In the CO-OP Approach™ the main focus is helping clients to learn to perform the everyday activities (achieve the functional goals) that are important and meaningful to them.

CO-OP draws on learning and cognitive behavioral theories to help child and adult clients learn a problem solving strategy, which is then used to achieve their goals. The problem solving strategy is also called a global cognitive strategy. The therapist uses ‘guided discovery’, a CO-OP technique, to help the client to think through how to perform an activity (e.g. skipping rope, printing, grocery shopping) and to think about how they might overcome their own specific performance challenges with that activity. The therapist asks questions about the client’s performance to help them think through what they need to do differently to better perform the activity. This leads to a discussion between the client and the therapist, rather than a traditional approach whereby the therapist gives the client direct instructions.

One of the observable differences between CO-OP and other approaches is that CO-OP involves more time talking about how a client performs an activity. The reason for this is to guide the client to develop a solution independently. In turn, this leads to the client developing problem-solving skills that can be applied or transferred to other activities.

History of the CO-OP Approach™

CO-OP was initially developed for children with developmental coordination disorder (DCD), a condition that makes it challenging to learn new motor skills. CO-OP has several important components, which were developed over ten years of research comparing traditional treatment approaches to new interventions. Traditional approaches to treatment for children with motor-based problems focused on breaking down the activity and treating performance components. For example, if Anna, a child with DCD, is working on the task of printing, a therapist might set “improving fine motor skills” as a treatment goal, believing that improving fine motor skills must lead to improvements in printing. Similarly, if Jim, after having a stroke, is learning to walk confidently in a busy shopping mall, the treatment goal might be to “improve balance”. These treatment goals were based on the idea that performance would generally improve for activities once the impaired underlying components got better.

Examples of
Impairment-Based Goals

Examples of
Performance-Based Goals

Improve balance

Improve upper extremity motor control

Improve memory

Improve endurance and activity tolerance

Typing on a computer

Cutting with a knife

Sewing with a needle

Washing hair

The CO-OP developers learned that these approaches did not usually improve performance. When comparing traditional approaches to contemporary treatment, one study showed that direct teaching could lead to improved performance in specific activities in children with DCD. This suggested that using a learning approach might be more successful than traditional impairment reduction approaches. Using this perspective, the CO-OP developers drew on ideas from Donald Meichenbaum, who originally coined Goal-Plan-Do-Check, to inform the development of a new global problem solving approach. The new approach was initially called Verbal Self Guidance, but as more was learned and components were added, it became CO-OP. In 2001, a randomized control trial was published comparing CO-OP to traditional therapy in children with DCD, demonstrating a significant effect of CO-OP in skill performance. This studyalso showed that the problem solving skills learned during CO-OP could be applied to other activities, with different therapists and in different environments outside of therapy. Because of CO-OP’s success, the two main developers, Helene Polatajko and Angela Mandich, published a textbook (2004) detailing the theoretical foundations and key features of the approach. The textbook was specifically aimed at using CO-OP in a pediatric DCD population. Since its publication, several peer-reviewed studies have suggested the CO-OP Approach™ was effective in other populations, including children with Asperger’s syndrome and cerebral palsy and adults with traumatic brain injury and stroke.

Client-centred: CO-OP is founded on the philosophy of client-centred practice. Client-centredness refers to the idea that the client is an active participant in therapy, where their perspective is respected and their goals are a priority. CO-OP requires that clients are able to identify goals that are important to them, which helps to ensure client-centredness and enhance clients’ motivation throughout therapy.

Performance-based: CO-OP’s main objective is skill acquisition (or enhancing performance), and therefore the focus of therapy is learning specific skills that are important to the client. Thus the client works directly on the specific skills that she or he wants to achieve, e.g. handwriting, rather than components, e.g. fine motor skills.

Problem-solving: Therapists guide clients to solve performance-based problems using a global cognitive strategy (Goal-Plan-Do-Check) to discover domain specific strategies that are specific to individual clients, goals, and situations. Teaching the client to use cognitive strategies independently is one of the main objectives of the approach.

Who can benefit from CO-OP?

CO-OP was initially developed for children with developmental coordination disorder (DCD), but since has been used with several other populations. CO-OP has demonstrated efficacy with people living with the following conditions:

Asperger’s syndrome

Cerebral palsy

Acquired brain injury

Stroke

Developmental delays

Older adults with self-identified cognitive impairment.

CO-OP research is ongoing with other populations, such as with children with dystonia.

CO-OP is a versatile approach with multiple applications across ages and diagnoses. Despite its versatility, it is recommended that clients have certain pre-requisite skills. These are as follows:

The client must be able to select occupations or activities that they would like to learn or for which they would like to improve their current performance level. The client identifies these occupations through an interview using the Canadian Occupational Performance Measure (COPM).

The client must have sufficient language fluency in order to discuss their performance with the therapist.

The client must have sufficient cognitive ability to benefit from CO-OP’s problem solving approach. Research has demonstrated that clients with cognitive impairments can benefit from CO-OP, so sufficient cognitive ability relates to the ability to learn and remember from session to session.

Clinical Objectives

CO-OP has four main objectives. These are:

Skill acquisition

Skill acquisition is the primary objective of CO-OP. Clients acquire the skills they select as personally meaningful.

Cognitive strategy use

Clients learn how to use cognitive strategies to solve performance problems. They learn to use the global cognitive strategy Goal-Plan-Do-Check as a problem-solving framework for all performance issues they encounter. Within the Plan phase, they learn to discover domain-specific strategies that are specific to that individual and the particular skill and context.

Generalization

Clients are able to do the occupations or activities they learned in multiple environments, rather than just in therapy. This is called generalization. For example, if Anna identifies in therapy that she needs to stabilize a piece of paper to improve her printing, she will also be able to do this at home and in her classroom.

Transfer

Skills learned in CO-OP, including both the occupations and using the global cognitive strategy, are transferred to facilitate the learning of new skills as needed. For example, if Jim learned to use Goal-Plan-Do-Check to learn to walk in the mall, he may go on to use this problem solving strategy to learn to cut his lawn, or even for a very different skill, such as playing guitar.

7 Key Features

CO-OP is made up of seven key features, which are all believed to contribute to CO-OP’s effectiveness.

Key Feature 1: Client-chosen goals

At the beginning of therapy, the therapist helps the client to identify three goals. Since CO-OP is a client-centred approach, the goals are set in partnership with the client and parents/significant others. If goals are personally relevant, the client is more motivated to learn and more engaged in therapy. This in turn leads to better skill generalization (learning a skill outside the therapy environment) and transfer (learning other novel skills).

Key Feature 2: Dynamic Performance Analysis (DPA)

Dynamic performance analysis (DPA) is an observation-based strategy used by the therapist to identify clients’ breakdown in performance and to help the therapist begin to prioritize which performance problems to address. DPA also helps the therapists to begin thinking about strategies that will support skill acquisition and/or goal attainment. DPA differs from traditional activity analysis in that it is performance-based rather than component based. For example, if a client wants to ride a bike the therapist will look at which parts of bike riding are not successfully (client has trouble steering or is not pedaling quickly) rather than look for components that are weak (poor balance, muscle weakness).

Here is an example comparing a DPA vs. Task/Impairment Analysis:

Riding a Bike

DPA

Task/Impairment Analysis

Trouble steering

Feet are slipping off the pedals

Slow pedaling speed

Decreased grip strength of (L) hand to hold handle bars

Impaired balance

Low tone

Key Feature 3: Cognitive Strategy Use

Cognitive strategies are conscious tools that people use to support performance while a skill is being learned. In CO-OP, two types of cognitive strategies are used: a global strategy, and domain-specific strategies.

Global Strategy

Domain Specific Strategies

A global cognitive strategy, also known as a metacognitive strategy, is a structured problem-solving framework that can be used in any situation and includes an evaluation component. In CO-OP, the global cognitive strategy is Goal-Plan-Do-Check. Clients are taught to identify a Goal, Develop a Plan, Do the plan, and Check to see if they Plan worked.

Domain specific strategies are specific to an individual, the skill being learned, and the context. They include body position strategies (Jim lifts his knee high when walking), attention to doing (Anna focuses on the lines when she is printing), task specification (Anna notices the long stick on the letter “b” is on the left side), task modification (to reduce fatigue, Jim cuts half the lawn one day and the other half the next), and verbal motor mneumonics (Anna thinks the letter “s” looks like a snake).

Key Feature 4: Guided Discovery

Guided discovery is a means of providing both instruction and feedback in which the therapist asks questions and provides hints and cues so the client can discover performance problems and solutions on her or his own. Self-discovering of solutions is believed to be associated with better generalization and transfer of skills.

When using guided discovery, therapists are asked to remember the following:

One thing at a time

Ask, don’t tell.

Coach, don’t adjust

Make it obvious

Key Feature 5: Enabling Principles

CO-OP is a client-centred, performance-based, problem-solving approach focused on skill acquisition through cognitive strategy use and guided discovery. Enabling principles are used throughout to support all CO-OP processes. The enabling principles are:

Make it fun/make it engaging. For children and adults alike, learning is more likely to occur if the process is enjoyable. For children, this may involve using games, fun challenges, or silliness. For adults, it involves encouraging their self-motivated and self-directed exploration of problem solving solutions to their performance challenges.

Work towards independence. Similar to how learning is promoted by removing prompts, the therapist should remove their verbal and physical support as the skill improves.

Promote generalization and transfer. The therapist seeks opportunities to directly promote generalization and transfer, such as explicitly asking the client how their strategy will work outside the practice setting and what other skills it can be used with.

Key Feature 6: Parent or significant other involvement

Parents and significant other involvement is an important component in skill acquisition and generalization and transfer. The therapist should provide education to parents/significant others about CO-OP and its underlying principles. Parents and significant others are encouraged to participate in goal setting and attend at least three sessions to observe how CO-OP is carried out.

Key Feature 7: Intervention format

While CO-OP’s intervention format has undergone some alterations to best meet the needs of certain populations or delivery methods, the overall structure remains the same:

Pre Intervention

Three goals are established and baseline performance on goals is evaluated.

Intervention

In the first session, the global cognitive strategy (Goal-Plan-Do-Check) is taught. In subsequent sessions, the global strategy is used together with DPA and guided discovery to help the client discover domain-specific strategies to overcome performance issues and acquire skills. In “traditional” CO-OP, there are 10 one-on-one intervention sessions approximately 45-60 minutes; adaptations have included more or less sessions, group delivery, and telehealth delivery.